Sunday, December 28, 2014

I see patients with abdominal pain every day. Over my career, I’ve sat across the desk
facing thousands of folks with every variety of stomach ache imaginable. I’ve listened to them, palpated them,
scanned them, scoped them and at times referred them elsewhere for another
opinion. With this level of experience,
one would suspect that I have become a virtual sleuth at determining the
obvious and stealth causes of abdominal distress.

I wish it were the case.

Some Cases Defy Sleuthing

The majority of cases of chronic abdominal pain that I – and
every gastroenterologist – see will not be explained by a concrete
diagnosis. Sure, I’ve seen my share of
sick gall bladders, stomach ulcers, diverticulitis, bowel obstructions,
appendicitis and abdominal infections, but these represent a minority of my
afflicted patients.

Patients with acute abdominal pain are more likely to
receive a specific diagnosis, such as those listed above. However, patients who have abdominal distress
for years, which constitute most of my stomach pain patients, usually will not
have a specific, explanatory diagnosis even though these patients often feel
otherwise.

Many of these patients come to the office advising me that “their
diverticulitis is acting up” or that “their ulcer is back again”. Usually, this is not the case and they may
never have had diverticulitis or an ulcer in the first place.

Physicians often assign these patients a diagnosis of
irritable bowel disease or functional bowel disease, which is a rather
amorphous entity that cannot be detected on available diagnostic testing. The labs and scans and scopes are all normal
in these folks. I believe that the
condition is real, but it is a frustrating condition that is difficult to
define. It often coexists with other
chronic painful conditions, such as fibromyalgia, chronic pelvic pain and
migraine headaches.

This is tough for patients and a medical profession that
strive to label every symptom numerically and quantitatively. The body does not work this way.

Of course, I may be missing true diagnoses in some of my
chronic pain patients. Medical science
isn’t perfect and neither am I. How many celiac disease patients have I
overlooked? Should I test every
individual who has a cramp now and then for celiac disease so I don’t miss a
single case? If every physician adopted
this approach for celiac disease – and a hundred other conditions – we would
elevate our current practice of overdiagnosis and overtreatment beyond the
stratosphere.

So, how much testing should a patient with chronic nausea or
abdominal pain receive? Patients and
physicians don’t always agree here. How
much cost and care are patients, physicians and society willing to expend to
approach 100% chance of not missing a diagnosis? Is your answer the same if you or a loved one is the patient?

Sunday, December 14, 2014

Over the past decade, there has been renewed effort to increase the quality of colonoscopy. New data has demonstrated that colonoscopy quality is less than gastroenterologists had previously thought. Interestingly, colonoscopy is less effective in preventing colon cancers in the right side of the colon compared to the left side. Explanations include that some pre-cancerous polyps in the right side of the colon are more subtle to recognize and that the right side of the colon has many hidden areas that are difficult to visualize. New examination techniques and equipment are addressing these issues.

The goal of colonoscopy is not to detect cancer; it is to remove benign polyps before they have an opportunity to become malignant. A new measure of medical ‘quality’ is to record how often gastroenterologists (GIs) remove polyps from their patients. For example, if a GI only detects polyps in 5% of patients, which is under the quality threshold, then someone will conclude that this physician is not diligent. So, now GIs may be scouring the colons to remove every pimple in order to reach threshold. While this may result in higher ‘quality’ colonoscopies, will patients actually benefit? We don’t know. Pay-for-performance and other quality initiative create opportunities and incentives to game the systems. Is our mission to help patients or to play the game?

﻿

An interesting issue regarding colonoscopy quality has been published in medical journals. GIs who are doing colonoscopies all day long lose their edge as the day progresses. It may be that that physician fatigue is a factor, or that afternoon patients are not as thoroughly cleaned out as morning patients are. This issue has been covered in the press and patients have asked me about it. I am not aware that my procedural quality is time dependent, but I haven’t looked at my own data. I wonder what my optimal colonoscopy time slot is. Perhaps, I should run my data and then charge fees in accordance with my polyp detection rate. In other words, if a patient is seeking a bargain colonoscopy, then he gets the last slot of the day. However, if a patient wants concierge medical quality, and is willing to put some cash on the line, then he’ll get scheduled accordingly.

I wonder if other medical specialties, including primary care, experience quality decay over the course of the day. I am interested if any physician readers are aware of published data on this issue or can share relevant personal experiences.

The lessons gleaned from the lower portion of the alimentary canal may apply beyond the medical arena. Do other professions perform better in the morning than they do in the afternoon?

Here are some studies I propose, which can be funded in our government’s usual manner – borrow.

Profession Quality Measurement per Shift Hour

Policeman Arrest Record

Thief Successful Robberies

Financial Advisor Profitable Advice

Politician Promises Kept

Stage Actor Lines forgotten

Judge Decisions Reversed

Since pay-for-performance is the panacea that will cure the medical profession, why shouldn’t we share it with the rest of you?

Sunday, December 7, 2014

This blog is devoted to an examination of medical
quality. Cost-effectiveness is woven
into many of the posts as this is integral to quality. Most of us reject the rational argument that
better medical quality costs more money.
Conversely, I have argued that spending less money could improve medical
outcomes. Developing incentives to
reduce unnecessary medical tests and treatments should be our fundamental
strategy. Not a day passes that I don’t
confront excessive and unnecessary medical care – some of it mine - being
foisted on patients.

At one point in my career, I would have argued that
physicians and hospitals were motivated only to protect and preserve the health
of their patients, but I now know differently.
Payment reform changes behavior.

As an example, it is impossible for a patient with a stomach
ache who is seen in an emergency room to escape a CAT scan, even if one was
done for the same reason months ago. I
saw a patient this past week with chronic and unexplained abdominal pain. She has had 5 CAT scans for the same pain in
recent years. This is a common
scenario. Once reimbursement policy
changes to punish physicians and hospitals for overtesting, we will witness the
Mother of All Medical Retreats!

Are 5 scans enough?

Physicians and the public have an interest in preserving
medical resources to serve society.
There is an emerging debate if physicians who are counseling patients
should be mindful of society’s needs while in the exam room. In other words, if I am prescribing a medicine
for a patient with Crohn’s disease that costs $25.000 annually, should I also
be considering if this is a wise use of society’s resources? Would this money be better spent giving
influenza vaccines (‘flu shots’) to uninsured or medically underserved individuals? If you were my patient, do you expect that I
am focused exclusively on your medical interests regardless of the cost? Do I have a responsibility to consider how my
advice to you impacts on others’ health since health care dollars are finite? Should patients be willing to sacrifice their
own medical care in order to serve the greater good?

Cost-effectiveness is presumed if someone else is paying the
bill. If patients had some skin in the
game, then they would exert some restraint on the current frenzy of diagnostic
testing and treatment. If my patient
cited above had to pay a portion of the 5 CAT scans that she had undergone, there
may have been only one scan. And, if the
hospital and the radiologists were paid only for necessary testing, there would
have been a similar outcome.

More medical care often means lower medical quality. How much longer do we want to pay more to
receive less?

Sunday, November 30, 2014

This is the only Thanksgiving holiday in my memory that I
was not on call for hospital work. Physicians,
like many other folks, are not automatically off on holidays and weekends. I’m not complaining here, but there are times
that I am envious of individuals who are home on every weekend and
holiday. Americans need health care,
law enforcement, and various emergency services even on days of national
leisure. When I am driving to the
hospital on one of those days, I remind myself that the sick person I am headed
to see has a much worse deal than I have.

I have been bestowed with many blessings, and I am grateful
for all of them. Some of them, I may
have earned, while others just fell my way.
Similarly, life’s travails can
result from a bad decision or just bad luck.
Life isn’t fair.

Spread Sunlight

I admire folks who always spy a rainbow through a storm, and I want to be like them. Appreciating one’s lot in life, especially a midst dark days, brings much
light into the world. It becomes a
contagion for good. The opposite
approach becomes a powerful force spreading discontent and unhappiness and has a
wide ripple effect. We've all seen this. There’s a reason
that most of us enjoying spending time with folks who exude sunlight. We don’t all have to be supernovas that can
enlighten the universe, but we can try to spew off enough photons to bring some
light into the world.

Last week, my family converged in New York City to surprise my mother
for a milestone birthday. She was in the
presence of the most important people in the world to her. A week later, I am still in the rarefied aura
of this unforgettable event. I am so thankful for this
incredible blessing.

Let's seek out light and spread some of our own.

President Lincoln's 1863 Thanksgiving Day Proclamation opens with the following sentence.

The year that is drawing towards its close, has been filled
with the blessing of fruitful fields and healthful skies.

Remembering what his world was like in 1863, we can agree that this man could see light during the darkest days we ever had. Our gratitude endures.

Sunday, November 23, 2014

We’ve all heard or used the phrase, ‘leave it to the
professionals’. It certainly applies to
me as the only tools that I can use with competence are the scopes that I pass
through either end of the digestive tunnel.
Yeah, I have a ‘toolbox’ at home, but it is stocked similar to the
first-aid kit in your new car, which contains a few BandAids, adhesive tape
and, hopefully, the phone number of local doctor. My home tool box has an item that can practically
fix anything – the phone number of a local handyman.

It is essential to know one’s limitations, regardless of
one’s profession.

Politicians shouldn’t speak authoritatively as if they are
climatologists.

Gastroenterologists should not prescribe chemotherapy, even though
we are permitted to do so.

Bloviating blowhards on cable news shows are likely not
military experts.

The guy who fixed your toilet might not be a top flight
kitchen remodeler even though his business card includes home remodeler, along with
railroad engineer, IT professional, seamstress and stand up comic.

Some of us are good at a lot of stuff. Some of us have a narrower, but deeper range
of competence. Yes, we’re all good at
something, as our moms and teachers taught us during our early years. Without doubt, most of us are not good at
lots of stuff, and it’s important to know where our comfort zone approaches the
chaos zone. In my own profession, it is
absolutely critical that physicians readily solicit assistance from a colleague
when additional knowledge, experience or judgment is needed. Asking for help to help a patient is
evidence that the physician is focused on his patient’s welfare. Every doctor has witnessed circumstances when
a physician is reaching too far beyond his tool box, and it’s not pretty.

Should a surgeon perform a complex operation that he only
seldom performs?

Should a local oncologist treat a patient’s rare cancer or
refer the patient to the expert downtown?

How long should an internist struggle with a patient’s hypertension
before recruiting an expert?

If an allergist’s patient keeps losing weight, is it time to
consider a cause beyond the scourge of gluten?

Last year, our practice needed some restructuring. We met with our accountants for advice on
streamlining and managing our practice.
I was impressed how quickly these pros looked over our financial
statements and readily understood the state of our practice. Of course, these guys see the world through Excel
spread sheets, just like we GI physicians do through our colonoscopes. To us physician clods, these reams of number
filled pages containing every permutation of various financial reports were
encrypted codes that would require NSA cryptographers to decipher. Most physicians are not good businessmen,
although many feel otherwise. Luckily,
my partner and I know the truth about ourselves. We didn’t ask the accountants for a ‘second
opinion’. We came to them first, and we’re
glad we did. I presume that when they
need a colonoscopy, they won’t try it themselves.

Sunday, November 16, 2014

A few days before I wrote this, a patient had a complication
in my office. I have discussed on this
blog the distinction between a complication, which is a blameless event, and a
negligent act. In my experience, most
lawsuits are initiated against complications or adverse medical outcomes,
neither of which are the result of medical negligence. This is the basis for my strong belief that
the current medical malpractice system is unfair. It ensnares the innocent much more often that
it targets the negligent.

I performed a scope examination through one of the two
orifices that gastroenterologists routinely probe. In this instance, the scope was destined to
travel inside a patient’s esophagus on route to her stomach and into the first
portion of the small intestine. Sedation
was expertly administered by our nurse anesthetist (CRNA). The procedure was quickly and successfully
performed. The patient’s breathing
became very impaired and her oxygen level decreased markedly, a known and
uncommon complication of sedation medications.
We took the appropriate measures, but her low oxygen level did not
respond.

At that point, our experienced and calm CRNA decided to
intubate the patient by passing a breathing tube into her lungs, in the same
manner as is routinely performed prior to surgery. The RN on the case, an ICU veteran, showed
how quickly and superbly her medical skills and judgment could be recalled. In decades of medical practice, I had never
had a patient whose scoping test and sedation led to a breathing tube
insertion. Moreover, this procedure was performed in our outpatient ambulatory surgery center, not in the hospital, so drama like this is exceedingly rare.

Physicians prefer to see drama in the theater.

The patient’s oxygen level immediately returned to normal
and she was transferred to the hospital in stable condition. She was appropriately treated and discharged
after a few days.

I was so grateful to have a team in place that had the
skills to rescue a patient who was in a dire situation. I told this to them directly and they seemed
to regard the matter in a more routine manner than I did. They saved her life. Nothing routine about this, as I see it.

For nearly all of the patients we see in the office, our
staff is overqualified. But, once or
twice a year, we need these folks on site, locked and loaded.

Physicians and the rest of us need back up. Do you have a contingency plan in your job if
a crisis befalls you? Will you wait for
a catastrophe before implementing one?
We’ve all heard vignettes about cities who were warned about a dangerous
intersection, but failed to ask until a tragedy occurred.

Finally, if someone helps you out of the abyss, give the
credit to whom it is deserved. Conversely, if something goes wrong and it’s
your fault, do the right thing.

Sunday, November 2, 2014

The Ebola hysteria continues. True, we might have a greater chance of being
struck twice by lightning, but the press would have us think we need to
purchase Hazmat suits for our families just to be prepared. I’m surprised that an entrepreneur hasn’t at least
constructed prototypes for Hazmat suies for newborns, popular dog breeds, pet
rodents and heirloom tomatoes.

Tomatoes?

Yes, tomatoes. I
have not heard any authoritative official from either the NIH, the CDC the WHO
or Medicins Sans Frontieres (Doctors Without Borders) who have stated
unequivocally that you cannot contract Ebola from an heirloom tomato. To me, the hypothesis is entirely plausible
as the sneaky virus can hide in the
heirloom’s surface crevices just waiting and hoping to gain access into an
unsuspecting mucous membrane.

Smooth Skin Tomatoes Probably Safe

As of this writing, there are 159 contacts in Ohio who have
had contact with an Ebola infected nurse who for reasons known but to God was
cleared by the CDC to board a commercial airplane with a fever after she had
treated an Ebola patient in Texas. Each
day, the number of Ohio contacts grows, so by the time these words are posted on
Sunday, I expect that there will be more contacts.

Gerbils Need Ebola Protection

The definition of what constitutes contact with an Ebola
patient is evolving. As of today, the
new and improved definition of contact is being an enclosed space with the
patient for any length of time. Hmm, if
I am watching the Cleveland Cavaliers in our downtown stadium from the last
row, and an Ebola patient is in the first row on the opposite side, am I now
considered a contact? Would all 10,000
fans be forced to enter into a 21 day period of quarantine?

Does it matter that medical experts have consistently
explained that you cannot catch this virus unless the infected individual is
symptomatic and you are within reach of that individual’s bodily secretions?

An Ohio school was closed as a staff member was on the
Frontier airplane that the nurse had traveled on although on a different
flight. Two hospitals in Cleveland sent
nurses home with pay and admitted publicly that this was for PR protection, not
for patient protection. What hope is
there when our medical institutions are lubricating our hysteria instead of
battling it?

This past Monday, I noticed a new procedure had been
implemented in our office. On the advice
of local and state medical authorities, we were asking every patient who enters our
office, if they have in to West Africa or had contact with an individual who
has been there. This nonsensical policy would protect no
one. There are zero known Ebola patients
in Ohio at present. This is a difficult
disease to contract as contracting this virus requires that one is in direct
contact with bodily fluids of an infected person. Querying every patient about recent travels
from West Africa only feeds the hysteria, while it burns up our staff’s
time. Asking Granny who comes to see us
from her assisted living facility if she’s been to Sierra Leone recently, doesn’t
seem to be sound preventive medical policy.

I think that our moratorium on heirloom tomato ingestion makes more sense than the Ebolaphobia policy. Can this post go viral?

Sunday, October 26, 2014

Who says that bipartisanship is dead? Just recently, Governors Cuomo and Christie –
a Democrat and a Republican – were shoulder to shoulder as they announced a
new and improved Ebola policy to protect their voters, I mean citizens. Now, every individual who was arriving at Newark
and Kennedy International Airports from Liberia, Guinea and Sierra Leone who
had direct contact with an Ebola patient, would face a mandatory 21 day
quarantine.

This policy exceeds restrictions advocated by the Center for
Disease Control and Doctors Without Borders, two organizations who presumably
are better qualified in infection control than politicians are.

Might this policy discourage our health experts from
traveling to West Africa to help to control the Ebola epidemic as they would
face a 3 week quarantine upon their return home?

Might some folks who are returning home who don’t agree with this new policy lie about their Ebola contacts?

What if travelers returning home from West Africa didn’t
touch down in New York or Newark? Don't the other 48 states deserve to be safe?

Does this policy seem more political than medical?

Future CDC Director?

Future NIH Director?

Maybe the governors’ new edict doesn’t go far enough? I'm surprised they did not consider the
following scenarios.

If an Ebola patient in Sierra Leone sends an email to a New
Yorker, should the American be required to take his temperature twice a day?

If a Rutgers University student looks up Ebola information
on an iPad, and used the touch screen without two sets of surgical gloves,
should the student be quarantined and the iPad confiscated?

If a Manhattan commuter enters a cab driven by a Liberian…

Why stop at Ebola?
Why not force returning passengers who have been exposed to influenza,
which unlike Ebola, is extremely contagious via air, to be quarantined?

There is a reason that politicians should not make health
care policy. Let them do what it is that
they do best – saying and doing anything to get elected. Will other governors now compete to establish
the strictest guidelines?

Scientists are testing an Ebola vaccine. We pray for their success. I hope that the NIH is working on a vaccine
against hysteria. I know two politicians
who need it desperately.

Sunday, October 19, 2014

While I haven’t devoted significant space on this blog to
the news media, it is not because I do not have strong opinions on the current
state of journalism. Indeed, I could
write an entire blog on the subject, and many have.

News acquisition and analysis have always been important
facets of my adult life. I spend many
hours every week reading various newspapers and other materials to gain new
perspectives on the issues of the day. Nearly every morning, I send items of interest to a close circle of friends and family. I
read news and opinion, although sometimes it’s hard to tell one from the
other. I am always drawn to opinions that differ from my own. While there is excellent
journalism today, the profession is deeply flawed by a blow-dried approach that
appeals to our tabloid lust and their desire for increased ratings.

Just because it’s above the fold on Page 1, doesn’t mean it truly
deserves this prime real estate. Pick up
your own newspaper and see what the leading articles are. It’s likely to be some local crime outbreak,
while news that really matters is either a small item pages later, or may not
appear at all.

TV News - If It Bleeds, It Leads!

Turn on CNN. Set
your stopwatch to measure how many minutes it will take before the bright
banner of BREAKING NEWS flashes across the screen. All that’s left is for Wolf Blitzer to
announce:

BREAKING NEWS!

HERE’S
A COMMERCIAL THAT YOU CAN'T MISS!!

How has the media performed with the Ebola issue? Poorly, in my judgment. First, the coverage has been absolutely suffocating on
major TV stations and has been on Page 1 of newspapers for days now. Is this an important issue? Of course.
Are there public health ramifications?
Definitely. Has the media
heightened public fear beyond the science?
Without question.

When the media, particularly television, sinks their fangs
into an issue, they will feed upon it until either the ratings start to ebb or
some new fresh meat draws them away.
Remember how CNN covered the Malaysian airplane disappearance?

While Ebola is clearly newsworthy, the number of infections
and fatalities that have occurred here in the U.S. can be counted on one hand,
with a few fingers to spare. My point
is that the coverage has been disproportionate to other issues that
have been sidelined, as the media routinely does.

30,000 Americans will die of flu this year

11,000 expected U.S. deaths by firearms this year.

About 100 U.S. highway fatalities daily with a yearly estimate of
30,000 victims

Where’s the proportionality? While every life is sacred, why are big
stories buried and much smaller ones sensationalized? Last night, I came home and declared that my
domicile would be an Ebola-free zone for the evening. This meant there would be no TV news for us. I feared that even turning on a
random TV channel could violate my edict as Ebola coverage is omnipresent. To make sure that we were in compliance, we pursued a safe entertainment
alternative. Netflix!

Ebola, a deadly virus, has gone viral in the press. The media, as always, perpetuates journalistic
contagion. Maybe they should be
quarantined?

Sunday, October 12, 2014

One catch phrase in
health care reform is cost-effectiveness.
To paraphrase, this label means that a medical treatment is worth the
price. For example, influenza vaccine,
or ‘flu shot’, is effective in reducing the risk of influenza infection. If the price of each vaccine were $1,000, it
would still be medically effective, but it would no longer be cost-effective
considering that over 100 million Americans need the vaccine. Society could not bear this cost as it would
drain too many resources from other worthy health endeavors. Economists argue as to which price point
determines cost-effectiveness for specific medical treatments. As you might expect, insurance companies and
pharmaceutical companies might reach different conclusions when the each
perform a cost-benefit analysis.

Remember, it’s not
just cost we’re focusing on here, but also effectiveness. If a medicine is dirt cheap, but it doesn’t
work, it’s not cost-effective. Get it?

Pharmaceutical
companies who are launching extremely expensive medicines often boast about the
medical benefits while they ignore the cost factor entirely. We see this phenomenon regularly when the
pharm reps come to our office or we are listening to a paid speaker.

Understandably, when
expensive medical care is being paid for by a third party, patients and their
families are not considering cost-effectiveness. They are focused on their own health and
welfare. If the doctor advises that our
mom needs chemo, we’re not wondering if the cost would be a fair allocation of
societal resources.

A new hepatitis C (HCV)
drug, Sovaldi, has recently been launched.
The 12 week course of treatment costs $84,000, or $1,000 a pill. This bargain doesn’t include the costs of
other drugs that are taken with Sovaldi as part of the treatment program. The cost of curing HCV, a worthy objective,
approaches $200,000 including the costs of medicines, physician services and
laboratory and radiology testing.
Assuming that there are over 3 million Americans who are infected with HCV,
the costs for curing them all approaches $300 billion. That’s billion with a ‘B’.

Electron Micrograph of HCV

Consider these facts
before deciding if hepatitis C treatment is cost-effective.

Most patients with HCV
feel well.

Most patients with HCV
are not aware that they are infected.

The majority of
patients with HCV will not develop cirrhosis or other serious complications of
the disease.

Many HCV patients who
are ‘cured’ of the virus would never have developed any health issues.They were silently infected.

Here’s what’s needed.

Identifying HCV
patients who are destined to develop severe complications.

Proof that treating
these patients changes the course of their disease.

HCV treatment that is
cost-effective.

TV or print ads about
HCV treatment suggest that you ‘talk with your doctor to see if the drug is
right for you’, When you do so, ask for the evidence that the
treatment will allow you to live longer or live better. Clearing your body of HCV sounds like a
triumph and is marketed as such, but this might not change your life at all.

Information is
power. I wish there was some way this
post could go viral.

Sunday, October 5, 2014

Giving prescription refills is not quite as fun as it used
to be. Years ago, we doctors would whip
out our prescription pads – often sooner than we should have – and we’d
scribble some coded language that pharmacists were trained to decipher. I’m surprised there were not more errors
owing to doctors’ horrendous penmanship.
On occasion, the Food and Drug Administration (FDA) would require a
pharmaceutical company to change the name of a drug so it wouldn’t be confused
with another medicine with a similar name.
The name of the heartburn drug Losec was too similar to congestive heart
failure drug Lasix, so the former drug name was changed to the familiar
Prilosec.

Nowadays, we physicians refill medicines with point and
click techniques within our electronic medical record (EMR) system. When this works, it’s a breeze. Three clicks and the refill has been
transmitted to the patient’s pharmacy. Alerts notify the physician of any
potential drug interactions with a patient’s other medicines. A record of all prescriptions and refills
becomes a part of the EMR system for all time.

Often, the drug interaction alerts are too sensitive. More than once, an alert has appeared warning
me that if I hit the ‘prescribe’ button, that my patient will suffer the same
fate as did the Wicked Witch of the West when Dorothy doused her with
water. When I can’t verify this doomsday
scenario using old fashioned techniques, I call the pharmacist directly who may
reassure me that the drug is safe to use.
So, I prescribe the drug knowing that my EMR system will document that I
have been duly warned and have chosen to cavalierly override the
admonition. Guess which profession likes
this EMR function?

Patients contact us nearly every day for prescription
refills. Of course, we beg them to do so
when they are in the office, but life doesn’t work this way and I understand
this. Here are some instances when I
will not refill the requested medicine.

One of my partner’s patients calls after hours for a refill
on narcotics

A patient wants a refill beyond my expertise. I won’t be refilling your cardiac medicines
as this should be done by the prescribing physician for several self-evident
reasons.

I haven’t seen the patient recently.

It is a common scenario for a patient whom I have not seen
for a year or two to request a refill on their GERD or heartburn medicine. When this occurs, I politely request that the
patient see me in the office first. The
patient may not grasp any urgency as he is feeling well and only wants another
year’s worth of acid-busting pills.
However, the moment I refill it, I am in effect accepting responsibility
for this action and any resultant consequences.
Here are some pitfalls with refilling a patient’s heartburn medicine who
has been AWOL.

Does this specific drug still make sense?

Can the dosage be lowered?

Have any new symptoms developed that might require
diagnostic investigation? Suppose the
patient has been losing weight, for example?
What if the ‘hearturn’ has worsened and a new disease is responsible?

Is the patient experiencing side-effects from the medicine that
he or his primary care physician might not appreciate?

Could the heartburn medicine interfere with new drugs that the
patient is now taking?

Is the patient up to date on other issues within a
gastroenterologist’s responsibility such as colon cancer screening?

Refilling routine medicines may not be routine and should be done with care and
caution. The patient from 2 years back who has GERD might think he
needs Nexium for his 'heartburn'. What if
his symptom is actually angina? Get my
point?

So, when we ask you to stop in for a brief visit, it’s not
because we delight in hassling you or are hungry for your copay. We’re trying to protect you and to keep you
well. Doesn’t this seem like the right
prescription?

Sunday, September 28, 2014

A medical student recently asked my advice on her decision
to pursue a career in dermatology. It
was about 25 years ago when my own parents encouraged me to pursue this
specialty. What was their deal? Perhaps, they anticipated future developments
in the field and were hoping for free Botox treatments? As readers know, I rejected the rarefied
world of pustules and itchy skin rashes for the glamor of hemorrhoids, diarrhea
and vomit.

My parents were making a lifestyle recommendation. Dermatologists are doctors who sleep
through the night. Spying one in a
hospital is a rarer sighting than spotting a liberal Democrat at a Michelle
Bachmann rally (unless a planted heckler). Nocturnal acne medical
emergencies are uncommon. And anyone
who has had cosmetic work done understands painfully that this is a cash
business.

Diagram of Skin

Luckily, the Whistleblower is thick-skinned

Here’s where some readers or Dermophiles will accuse me of
skin envy. Not true. Some dermatologists may be a tad thin-skinned
over this assertion, but facts are facts.
These docs have a soft lifestyle and earn much more money than most
physicians do. Sure, these guys and gals see some serious
stuff, but the nature of their specialty is less intense and frenetic than that
of other colleagues.

Many professions push back when it is suggested that they are
afforded unique and soft perks that most of us don’t have. Teachers, for example, never state out loud
that having every Federal holiday off, enjoying school vacations every few
months and having 10 weeks off in the summer are unbelievable soft padding that
no one else has. We know you work hard
under difficult circumstances and we respect you and your profession. But just admit that you have some
unbelievable professional cushions. This
won’t diminish your self-worth or contributions to society.

Many medical interns and residents don’t consider lifestyle
when they are making their career choice, and they should. Obstetrics is thrilling when you are 30 years
old. Fifteen years later when you are
overworked, tired and have your own kids, it may be slightly less thrilling to
bring new life into this peaceful world in the middle of the night on a regular
basis.

For me, leaving my own bed at an ungodly hour to haul out to
the hospital is an unwelcome activity. I do not relish being awakened with phone calls or having to
attend to an individual in the emergency room when the rest of Cleveland is
soundly snoring. While gastroenterology is a more taxing
specialty than the skin gig, it is still uncommon for me to have leave for the
hospital during the black of night. Since
we are in the era of medical hospitalists who are on staff around the clock,
there is only a rare need for me to make a personal appearance. On most nights, my scope rests securely in
its holster.

Do I think that medical students should consider lifestyle
as they are contemplating their future?
Absolutely. Indeed, the emerging
culture of the medical profession has morphed from the prior culture when doctors
worked 24/7 and interns were proudly on-call every other night. Medical doctors today are increasingly
employed by institutions, work shifts and delegate the hassles of hospital life
to hospitalists. Doctors are self-prescribing R & R.

Leisure, relaxation, avocations and personal time for
reflection are not evil pursuits. They
are the fuel that cultivates and sustains our humanity. Who wouldn’t welcome a little more humanity
in the medical profession?

Sunday, September 21, 2014

If you are a physician like me who performs procedures, then
rarely you will cause a medical complication.
This is a reality of medical life.
If perforation of the colon with colonoscopy occurs at a rate of 1 in
1500, and you do 3000 colonoscopies each year, then you can do the math.

Remember that a complication is a blameless event, in
contrast to a negligent act when the physician is culpable. These days, for many reasons, an actual
complication is confused or misconstrued as an error.

Some complications are more difficult on physicians than
others. For example, if I prescribe a
medication and the patient develops a severe rash, I do not feel personally
responsible. It’s the drug’s fault. However, when I perforate someone’s colon as
a medical complication, I feel responsible even if this act was a blameless
event which will occur at a very low but finite rate. (Of course, there are perforations of the
colon which result from medical negligence, but I am leaving these aside to
make my point here.)

I Didn't Cause This Rash. The Drug Did It!

I feel
responsible because my hand was on the instrument that caused harm. I can’t as easily blame the scope, as I
blamed the rash-causing drug. I’m sure that surgeons feel the same painful
emotions when they perform a routine operation and serious bleeding results
that requires additional surgery and complicates what should have been an
uneventful recovery.

When your hand is on the colonoscope or the scalpel, and the
unexpected happens, it’s an awful experience for the doctor even if we have performed
according to proper medical standards.

Of course, serious medical complications are much more
difficult for the patients and families involved than they are for us. But, we physicians suffer greatly when a
patient is harmed from a procedure that we recommend and perform. You can imagine how we torture ourselves
with second-guessing when these events occur.

Complications are inevitable. The only gastroenterologist who hasn’t had a
perforation of the colon is one who is brand new. So, if you are drawn to a gastroenterologist
because he has a 0% perforation rate, caveat emptor! Paradoxically, the most experienced
colonoscopists have accumulated many more complications over their career
because of a much higher volume of cases or that they are referred very
challenging cases by virtue of their skill and experience.

A medical complication is an especially difficult event when
it occurs in what was expected to be a routine outpatient examination. Patients who come to our office for a
screening colonoscopy understandably expect to be home 2 hours later. So do we.
On those rare occasions, when this recovery path is altered, we must have
a very serious, sober and unexpected conversation with the patient and the
family. Our plan is always to tell the
truth and reassure all involved that we will do all that we can to make it
right.

Medicine is not a simple or predictable endeavor. Sometimes, it can be rather complicated.

Sunday, September 14, 2014

Is your
doctor a hammer and you're a nail?
Here's some insider's advice coaxing patients to be more wary and
skeptical of medical advice. Should you
trust your doctor? Absolutely. But you need to serve as a spirited advocate
for your own health or bring one with you.
Ask your physician for the evidence.
Sometimes, his medical advice may result more from judgement and
experience as there may not be available medical evidence to guide him. Make sure you have realistic expectations of
the medical out me. And most
importantly, try as best you can to verify that the proposed solution is
targeted to your problem.

Is Your Doctor a Hammer?

Consider
a few hypothetical scenarios.

A
66-year-old patient has chronic right lower back pain. Physical therapy has not been helpful. Radiological studies show a moderate amount
of hip arthritis. A hip replacement is
flawlessly performed. The orthopedist
discharges the patient from his practice.
The pain is unchanged.

A
60-year-old patient has chest pains that are not typical for angina. Her internist arranges a stress test and the
results are equivocal. A cardiologist
performs a cardiac catheterization and a moderate narrowing is found in an
artery. A stent is successfully placed
in the proper location. The patient is
reassured that her cardiac pipes are all wide open. She returns to see him a month later
wondering why the pains have continued.

A
50-year-old patient sees his gastroenterologist for stomach pain. An ultrasound confirms the presence of
gallstones. The patient accepts the
specialists advice to have his gallbladder removed. The operation proceeds smoothly. You can guess the rest.

This is
not meant to serve as an indictment of the medical profession. The examples above have been highly
simplified to make a point. First,
making accurate diagnoses are complex undertakings that can frustrate even
seasoned diagnosticians. Patients'
medical histories are often vague and evolving.
Many diseases and conditions have clever mimics that can lead doctors
astray. Every doctor can regale you with
anecdotes detailing episodes when they have been fooled. There isn't a medical doctor alive who hasn't
fumbled over a case of chest pain.

Just
because medical advice doesn't lead to the desired outcome, doesn't mean that
the advice was wrong. I concede, of
course, that bad medical advice can cause adverse outcomes, a self-evident
statement.

Despite
the vagaries and uncertainties in the medical arena, physicians try as best we
can to propose a remedy that is directed to your symptom, rather than serve as
a fix for something that is not ailing you.
My advice to patients is that when your doctor is raising the healing
hammer, is to try not to get nailed.

Make sure
this inquiry is in your tool box.
"Doctor, can you please explain why the treatment will cure the
symptom that brought me to you in the first place?

Maybe a
hammer is the right tool for you.
Without doubt, the time to have this conversation is in advance of
pulling the treatment trigger. Having realistic expectations can prevent future
frustration when a treatment doesn't bring you to the end zone.

Pass laws
restricting access to the wrong type of food.
Former Mayor Bloomberg got stiff-armed on this approach by the
courts. It's also always fun to watch
folks argue over the definition of a 'wrong food'. The debate on which foods warrant prohibition
at least brings some entertainment into the public square. Imagine trying to achieve consensus over 20
or so food items that should be banned.
If this task were actually accomplished, cigarettes and alcohol would
still be legal. Make sense?

Initiate
a massive public education campaign to scare us skinny. Show ads of scary
pictures with scary music reminiscent of an iconic anti-drug ad (This is your brain on drugs...) from a few
decades ago.

Most
folks who are overweight want to be thinner.
The reasons why folks carry extra weight are complex and are not simply
because they eat too much. There is a
powerful mental component that for many people is part of the problem and must be part of the solution. Sure, caloric control
is fundamental, but many overweight people do not eat just to satisfy
hunger. They do so for other reasons
which must be attacked directly if a successful outcome is to be achieved and
sustained.

The quick
fix has been luring folks with false promises for generations. Infomercials on the air every day hawk agents
that will melt fat away, although there always appears a disclaimer in a font
size too small for the human retina to discern that states that 'results not
typical'. The threshold for recommending
bariatric surgery is getting progressively lower, and it has not hit bottom yet. My sense is that this treatment is becoming
regarded as a routine remedy, rather than a last resort measure after multiple other
attempts have failed. I suggest that
many dieters may not be as disciplined and determined with conventional weight
loss programs knowing that a bariatric rescue is available.

Obesity is a
serious health issue without an easy external cure. Weight
loss medicines are either ineffective or dangerous. Fad diets don't work. Gastric bypass surgery is a serious operation
that profoundly changes every day of your life by design when it is working properly.

Weight
loss can be viewed as two distinct tasks.
Losing weight and maintaining the loss.

Success,
in my view, will come from within.

Weight
loss is not a sprint, but is a long distance run. Consider this point. Very modest lifestyle changes over time can
deliver big results. Lose a pound per
month, for example. Do the math and
calculate your new weight 2 years later.
This cold math works the same way if we gain a pound each month.

Write
down your reasons why you are overweight.
Are these reasons stronger than you're desire and commitment to
change? If not, then get yourself to the
starting gate. Your marathon run is
about to commence.

Sunday, August 31, 2014

Labor Day is here.
Like many of our National Holidays, we have forgotten the meaning of the
day. Is Memorial Day a time to reflect
upon those who sacrificed so we would be free, or a time to grill burgers on
the barbecue? Same with the Fourth of
July. Martin Luther King Day is just a
day off for many of us. If greater participation
and reflection on MLK is the objective, then why would this day be on a Monday
when most of the country is at work? Even
Christmas, a holiday season that I enjoy but do not celebrate, has shed its
deep religious significance having become a commercial enterprise. This reality, I suspect, must sadden and
disturb many believing Christians.

Labor Day, when many of us will be laboring over charcoal-broiled ribs and chicken, was created to remember and honor this country’s labor
unions.

Triangle Shirtwaist Factory Fire 1911

While I am hostile the politics of unions today, I readily
acknowledge that they were a necessary response to egregious abuse by
management. The percent of workers who
are organized today, and their influence, has been steadily declining. Right-to-work support has risen as workers
and the rest of us resist practices such as non-union workers being compelled
to pay fees to the union. I do not
believe that an individual should be forced to join a union or to pay them fees. Such coercion violates the
free choice that a worker is entitled to, in my view. Yes, I know the argument that union
protections extend to non-union workers who should not receive a free
ride by enjoying benefits that they do not pay for. I simply believe that the right-to-work
argument is more persuasive.

I am not against unions, but I do not support forcing people
to pay them who do not wish to join.
If participation in a union will deliver greater benefits to workers,
then these workers will want to join on their own free will. If you have to force someone to do something,
then I wonder if the ‘benefit’ is real.

Years ago, while attending the National Storytelling Festival
in Jonesborough, Tennessee, I remember listening to professional storyteller Gay
Ducey tell a few thousand of us her rendition of the Triangle Shirtwaist Factory
fire in 1911, a disaster where nearly 150 workers perished, when they could not
escape from a burning building as the doors and exits were locked by
management. I was spellbound during her
hour long recitation, and I have never forgotten it.

Let’s give a nod to all those who go to work every day,
supporting their families, and bringing goods and services to all of us.

I support a Right-to-Read principle. I can’t compel anyone to read and meditate on
my weekly homilies. You have to want to
come here. And, I hope that you
will.

Sunday, August 24, 2014

So much in medicine and in life is done out of habit. We do stuff simply because that’s the way we
always did it. Repetition leads to the belief that we are doing the right thing.

In this country, we traditionally eat three meals each
day. Why not four or two?

We prefer soft drinks to be served iced cold. I’ve never tried a steaming hot Coke. Maybe this would be a gamechanger in the food
industry?

Life gets more interesting when folks question long standing
beliefs and practices forcing us to ask ourselves if what we are doing makes
any sense.

In the medical profession, a yearly physical examination was
dogma. Now, even traditionalists have
backed away from this ritual that had no underlying scientific data to support
it. Yet, patients would present themselves to
this annual event believing that this ‘check-up’ was an important health
preserver.

Here were some medical routines that were never questioned.

Yearly ear drum examinations with the otoscope. Always exciting.

Palpation of the abdomen.

Listening to the lungs with a stethoscope.

Testing your reflexes (Sure, this was fun, but did it help
anyone?)

Keep in mind that I am referring to components of the
physical exam that are performed on asymptomatic individuals who feel
well. Obviously, listening to a
patient’s lungs has more value if a patient has fever and a cough.

Yes, I recognize that there may be an intangible value in having a physician make physical contact with his patients, which some argue help to
create a bond in the relationship. This
may be true in part as patients have been taught to expect this from their
doctors. Indeed, a ‘hands off’ physician
may be construed by patients as being an inattentive or even an incompetent
practitioner.

Recently, the American College of Physicians issued a new
guideline published in the Annals of Internal Medicine stating that routine
pelvic examinations should not be performed.
Why? Because there is no persuasive
evidence that they do any good.

Hands Off Gynecologists!

Sure, there will be pushback. In medicine and elsewhere, there is often
resistance to change from those whose practices are being challenged. Review the following complex table that I
have prepared.

Procedure Under Review Resistors

PSA Urologists

Mammograms Radiologists

Colonoscopies Gastroenterologists

Term Limits Politicians

Tort Reform Take a guess

If all of the elements of a routine check-up were subjected
to scientific scrutiny, we might be shocked at how little of the exam
remained. This might create an unintended
benefit. It would free up time that we
physicians could use to talk more with our patients. So far, no scientific study has deemed this to be a waste of time.

Sunday, August 17, 2014

I’m all for free speech and I’m very hostile to
censorship. The response to ugly speech
is not censorship, but is rebuttal speech.
Of course, there’s a lot of speech out there that should never be
uttered. Indecent and rude speech is
constitutionally protected, but is usually a poor choice. We
have the right to make speech that is wrong.

Does First Amendment Apply to Physicians?

I relish my free speech in the office with patients. I am interested in their interests and
occupations and sometimes even find time to discuss their medical
concerns. I am cautious about having a
political discussion with them, but patients often want my thoughts and advice
on various aspects of medical politics, and I am willing to share my views with
them. I don’t think they fear that
politics or any other issue under discussion will affect their care. It won’t.

A Federal Appeal Court recently decided in a Florida case that physicians could be sanctioned if they asked
patients if they owned firearms if it was not medically necessary to do
so. Entering this information into the
medical record could also result professional discipline. The court was considering such gun inquiries
to be ‘treatment’ and not constitutionally protected speech.

I am on the record in this blog more than once that I do not
think we should look to the courts to make policy. Their task is simply to rule on the legality
of a particularly claim. In other words,
we should not criticize a legal decision simply because we do not like the
outcome. Nevertheless, this decision is
simply beyond wacky and could create a theater of the absurd in every
physician’s office

Could the following examples of physician inquires be prohibited?

A psychiatrist cannot ask about cigarette smoking as this is
not relevant to the patient’s depression.

An internist cannot ask what the patient’s hobbies are as
this is not germane to the medical encounter.

A gastroenterologist asks his patient who is a chef for a
recipe and risks professional sanction for crossing a red line.

A surgeon asks a patient’s opinion about the town’s new
basketball coach and hopes that this patient is not a planted mole recording
the conversation.

So for those physicians who practice in the 11th Circuit, no
gun inquires unless you can demonstrate with clear evidence that it has direct
medical relevance. The court left open
for now asking patients about sling shots, fly fishing and skeet shooting, but medical
practitioners are advised to consult with their attorneys regularly.

Apparently, idiotic judicial decisions can still be the law of the land.

Sunday, August 10, 2014

I read recently that the left coast state of California is
contemplating requiring physicians to submit to alcohol and drug testing. Citizens there will be voting on this
proposal this November.I do think that the public is entitled to be treated by physicians
who are unimpaired. Physicians, as
members of the human species, have the same vices and frailties as the rest of
us.

Traveling leftward

I have no objection to this new
requirement, if it passes. This will not be a stand-alone proposal on the ballot, but is a part of the ballot initiative. Why would trial lawyers in the Golden State
want to include it? The meat of their
ballot effort is to reverse effective tort reform that had been in place there
for several years. Click on the Legal
Quality category on this blog for a fuller explanation of why the medical
malpractice system has been screaming for reform, and is slowing getting
it. Sure, there are always two or more
sides to every issue. But, when the
different points of view here are fairly weighed, trial lawyers’
self-serving positions are overtaken. They offer a different spin, of course.
While I acknowledge the validity of some of their arguments, I believe
that the system they advocate helps very few at the expense of many more
innocents.

The California ballot initiative aims to increase the
financial cap for a medical malpractice award from $250,000 to $1.1
million. Trial lawyers and other supporters were concerned that the public may reject raising the cap as they have been enjoying the benefits
of tort reform. Focus groups supported
the notion that the public would find the drug and alcohol testing proposal
appealing, which would raise the probability of passage of the bill.

There’s nothing evil about any of this. Every player in every issue uses polling and
focus groups to create and tailor their message. (Ever notice how politicians claim they never
read polls whenever poll results are against them or their positions?) I’m sure that the insurance companies who
champion tort reform are using the same techniques to manage their
message.

But, voters there and the rest of us should recognize why
the drug and alcohol provision is included. It was just a spoonful of sugar to make the legal medicine go down. Why not just include the medical malpractice vote on the ballot by itself,?
We’ve seen our politicians use this same technique over and over
again. Add a popular poison-pill
provision to an unpopular piece of legislation.
When it’s properly voted down, criticize those who voted against it by
pointing out their opposition to the popular add-on provision. Follow this example.

Legislator A: I am
adding an amendment to the Quadruple the Minimum Wage Bill that would give all
veterans and their families free First Class seating on all domestic flights.

Legislator B: I am
voting against the bill because I think that quadrupling the minimum wage is
bad economic policy

Legislator A: Shame
on Legislator A for trashing our veterans who have sacrificed so much for this
country.

Should other professions be subjected to random drug and
alcohol testing? Which would you
suggest?

Will Californians see through the smoke here? We’ll find out this November?

There's a
philosophical divide among physicians also.
Would you prefer a liberal physician or a conservative
practitioner? I'm not referring here to
fiscal policy or legalizing recreational marijuana use. Consider the following hypothetical scenario
and the 2 physicians’ approach from opposite sides
of the medical philosophical spectrum. Which
physician would you choose?

Dueling Doctors

The
Patient: She is a 50-year-old female
with chronic fatigue syndrome (CFS). She
is only able to work part time because of her condition. She has consulted with an internist, an
infectious disease specialist and a naturopath, but her fatigue persists.

A new
treatment for CFS has just been launched by a reputable herbal supplement
company. Two well-designed studies
suggest symptomatic improvement in afflicted patients after 6 months of
treatment. As the product is an herb,
there is no formal Food and Drug Administration (FDA) oversight.

Physician
#1: "I'm reluctant to recommend this product, despite the optimistic
preliminary results from two medical studies.
These studies were funded by the herb company and there may be bias
present. Moreover, it is very typical in
medicine for initial results to be favorable, with unforeseen side effects and
complications emerging later when after more widespread use of a drug. I'm concerned that the FDA had no role in
validating that the drug is safe and effective for its intended use. Additionally, there is evidence that the active
ingredient in the product disrupts the immune system, which may have serious
future consequences that may not become manifest for several years or
longer. While CFS is decreasing your
quality of life, your condition has been stable and will never threaten your
life. I recommend holding off until we
have an FDA approved medicine for CFS or the herbal supplement has been used
long enough that we have a better sense of its safety and efficacy."

Physician
#2: "I recommend that you try this new herbal product. It is completely natural and showed promising
results in two medical studies.
Importantly, no serious side-effects developed in either study. Of course, we have no long term data on
safety, but the vast majority of herbal supplements on the market are
safe. No other treatment thus far has
been successful for you, and your condition is adversely affecting your
professional and personal lives. The choice is to try something new or to
continue suffering as you have been. Try
it for 6 months and then we’ll reassess."

So,
that's my herb blurb. This is a common
situation in the medical world where medical advice must pass through the prism
of Risks and Benefits. These analyses
are limited when the risks and benefits are unclear or disputed. Treatment acceptance also depends heavily on
the patient's risk tolerance. What if
the herb referenced above had a 5% risk of cancer? What if the herb needs to be taken
indefinitely? Clearly, when the disease
poses a serious medical threat, the patient may be willing to accept greater
risk of new or investigational therapies.

So, which
of these physicians would you choose for yourself? Are you a medical liberal or a conservative?

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About Me

I am a full time practicing physician and writer. I write about the joys and challenges of medical practice including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When I'm not writing, I'm performing colonoscopies.